La. Admin. Code tit. 48 § I-7525

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-7525 - Record Keeping

A. Medical Records

1. Identifying Information. The patient identification information such as name or ID number must appear on each page.

2. Entry Identification. Entries must be dated, signed, and credentials identified (MD, RN, etc.).

3. Contents. Each patient record must contain the following:

a. personal/biographical data including full name, age, sex, address, employer, home and work telephone numbers, and marital status;

b. next of kin or contact person;

c. pertinent medical history/information.

4. Storage. All medical records shall be protected from theft, fire, and unauthorized use. Open shelving may be utilized only when the patients/visitors do not have access to the storage area. Closed records must be maintained by the facility or its designee in accordance with the following:

a. a minimum of seven years from the date of last entry. After two years, records may be maintained electronically;

b. until the age of majority, plus seven years in the case of children or adolescents.

B. Facility Records. A facility must maintain records of credentials and other evidence that facility is in compliance with current standards of practice and licensing standards as listed below:

1. personnel records;

2. advisory board meeting minutes;

3. policies/procedures with annual approvals;

4. governing board meeting minutes; and

5. proof of hours worked for professional employees.

La. Admin. Code tit. 48, § I-7525

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 25:1850 (October 1999).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2197.